Brain and Mind 3: 79–100, 2002.
© 2002 Kluwer Academic Publishers. Printed in the Netherlands.

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Childhood Experience and the Expression of
Genetic Potential: What Childhood Neglect Tells
Us About Nature and Nurture

BRUCE D. PERRY

The ChildTrauma Academy, 5161 San Felipe, Suite 320, Houston, TX 77056, USA
(E-mail: [e-mail])

(Received: 15 April 2002; in final form: 23 April 2002)

Abstract. Studies of childhood abuse and neglect have important lessons for considerations of
nature and nurture. While each child has unique genetic potentials, both human and animal studies
point to important needs that every child has, and severe long-term consequences for brain function
if those needs are not met. The effects of the childhood environment, favorable or unfavorable,
interact with all the processes of neurodevelopment (neurogenesis, migration, differentiation, apop-
tosis, arborization, synaptogenesis, synaptic sculpting, and myelination). The time courses of all
these neural processes are reviewed here along with statements of core principles for both genetic
and environmental influences on all of these processes. Evidence is presented that development of
synaptic pathways tends to be a “use it or lose it” proposition. Abuse studies from the author’s
laboratory, studies of children in orphanages who lacked emotional contact, and a large number
of animal deprivation and enrichment studies point to the need for children and young nonhuman
mammals to have both stable emotional attachments with and touch from primary adult caregivers,
and spontaneous interactions with peers. If these connections are lacking, brain development both of
caring behavior and cognitive capacities is damaged in a lasting fashion. These effects of experience
on the brain imply that effects of modern technology can be positive but need to be monitored. While
technology has raised opportunities for children to become economically secure and literate, more
recent inadvertent impacts of technology have spawned declines in extended families, family meals,
and spontaneous peer interactions. The latter changes have deprived many children of experiences
that promote positive growth of the cognitive and caring potentials of their developing brains.

Archeology first documents evidence of written language
5000 years ago in the Middle East. The genetic potential
for humankind to learn and use written language had
been present, but unexpressed, for 200,000 years prior
to the first invention of written language.

One thousand years ago, less than 1% of the popula-
tion of Western Europe could read. Essentially all of
the population had the genetic potential to learn to read
yet this potential remained untapped until the advent of
universal public education.

In 1211, Frederick II, Emperor of Germany, in an attempt
to discover the natural “language of God,” raised dozens
of children in silence. God’s preferred language never
emerged; the children never spoke any language and all
ultimately died in childhood (van Cleve, 1972).

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More than 200,000 years ago, the first homo sapiens sapiens, our genetic ancestors,
began to spread across the planet. For 99 percent of the time our species has been
on this planet, we lived in small hunter-gatherer clans. Humans lived with few
material possessions, no written language, no complex world economy, advanced
technologies or systems of governance. The major predator of humans was (and
remains) other humans – usually from competing clans or bands. The lifespan was
short, infant mortality high and the overall population of on the planet only slowly
increased over tens of thousands of years. How different our Earth is today!

Only one of thousands of mammals on the planet, humankind – slow, naked

and weak creatures, biologically suited to few of the Earth’s many climates and
ecosystems – ultimately came to dominate the planet. Humankind is now capable
of living in all of the planet’s climates and harsh environments. No longer bound
by cold, absence of natural grains or migrating herds, the natural boundaries of
sea and sky, we humans – unlike any other of the planet’s species – have created
our own world. We have learned to cultivate natural grains and fruits – and now
alter their genome; to domesticate and now, create, other animal species; from
our own genetic capacity to make complex associations, symbolic representations
and 40 basic sounds we have created 10,000 languages, and invented writing; we
have invented belief systems, styles of governance, housing, economies – we have
invented ourselves. We have made our own world with its own rules. In good ways
and in bad, we stand out from all other species. So much so that we often forget
that we are ultimately accountable to the laws of nature.

Yet we are biological creatures, bound by the laws of nature to a time-limited

existence. We are conceived and born, live our lives and then we die. From concep-
tion to death, our biological matrix organizes in remarkably complex ways to create
multiple organ systems – bone and muscle, heart and liver, senses and brain. These
biological systems allow each of us to move through space and time in a host of
natural and, now, man-made, environments, interacting in complex ways with a
diversity of biological creatures and environments. Within that single lifetime the
range and variety in how we live is stunning. Genetically-comparable humans can
live as Inuit in the tundra of Nunavut, a banker on Wall Street, a hunter-gatherer in
the rainforest in Brazil. At times, a life is lived with grace and beauty, sharing with
and caring for others, creating ideas, objects and concepts never before known on
this planet. And at other times humans are cruel, ruthless and destructive – both
random and systematic in the ways we destroy, hate and kill. How is this possible
in the same species?

This question has been at the heart of centuries of debate on the “nature”

of humankind. Are we born evil – natural born killers or the most creative and
compassionate of all animals? Are we both? Does our best and our worst come
from our genes or from our learning? Nature or nurture? These questions have
tainted political, sociocultural and scientific processes for thousands of years. Its
simplicity – suggesting that the essence of a person is the inevitable product of one
or the other – genes or learning – is seductive. The human mind tends to prefer

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simple linear explanations rather than complex ambiguity. Unfortunately, simple
categorical explanations of humankind feed destructive belief systems and deflect
from a healthy process of inquiry about our true complexity.

We now know more about our genes and more about the influence of experi-

ence on shaping biological systems that ever before. What do these advances tell
us about the nature or nurture debate? Simply, they tell us that this is a foolish
argument. Humans are the product of nature and nurture. Genes and experience
are interdependent. Genes are merely chemicals and without “experience” – with
no context, no microenviromental signals to guide their activation or deactivation –
create nothing. And “experiences” without a genomic matrix cannot create, regu-
late or replicate life of any form. The complex process of creating a human being –
and humanity – requires both. The amazing malleability and adaptability of human-
kind is allowed by our genetically-mediated capacity to perceive and respond to
myriad environmental cues including the complex social-emotional milieu created
when humans live together; and the organ most sensitive and responsive to the
environment is the human brain.

The Human Brain

Humankind’s transient but magnificent rebellion against nature is allowed by the
brain. In ways not yet understood, activation of neural networks – chains of neurons
– allow us to think, feel and act. It is our brain which allows us to laugh, cry, hope
and act in humane ways. It is the brain that mediates our humanity – or not.

Yet the brain’s prime mandate is survival of the species. The human nervous

system senses, processes, stores and acts on information from the inside and
outside environments to promote survival of the species. Three key brain-mediated
capabilities must be present for our species to survive: individual survival, procre-
ation and the protection and nurturing of dependents. Failure in any of these three
areas would lead to extinction of our species. The brain, therefore, has crucial
neural systems dedicated to (1) the stress response and responding to threats – from
internal and external sources; (2) the process of mate selection and reproduction
and (3) protecting and nurturing dependents, primarily the young.

The primary strategy we use to meet these objectives is to create relation-

ships. Relationships which allow us to attach, affiliate, communicate and interact
to promote survival, procreation and the protection of dependents. It is the brain
that allows humans to form the relationships which connect us – one to another –
creating the myriad groups – that have been the key to our success on this planet.
It is not as independent and solitary individuals that we succeed; it through our
interdependent relationships – our families, clans, communities and societies – that
we survive and thrive. We need each other. Therefore, some of the most powerful
and complex neural systems in the human are dedicated to social affiliation and
communication.

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Yet even these essential neural systems do not develop without necessary exper-

iences. The neural systems which allow us to create relationships – and think, feel
and act – are the product of the interactive, dynamic processes taking place during
the history of each individual. These neural systems, then, are created, organize
and change in response to experience throughout the life-cycle. The time in life,
however, when the brain is most sensitive to experience – and therefore most easy
to influence in positive and negative ways is in infancy and childhood. It is during
these times in life when social, emotional, cognitive and physical experiences will
shape neural systems in ways that influence functioning for a lifetime. This is a
time of great opportunity – and great vulnerability – for expressing the genetic
potentials in a child.

Neurodevelopment

The mature human brain is comprised of 100 billion neurons and ten times as
many glial cells – connected by trillions of synapses all. A complex dynamic
of continuous activity, it is the product of neurodevelopment – a long process
orchestrating billions upon billions of complex chemical transactions.

In a few short years, one single cell – the fertilized egg – becomes a walking,

talking, learning, loving, and thinking being. In each of the billions of cells in the
body, a single set of genes has been expressed in millions of different combina-
tions with precise timing. Development is a breathtaking orchestration of precision
micro-construction that results in a human being. The most complex of all the
organs in the human body is the human brain. In order to create the brain, a
small set of pre-cursor cells must divide, move, specialize, connect and create
specialized neural networks that form functional units. This requires nature and
nurture. The key role of genetics and environment are outlined for eight of the
key neurodevelopmental processes involved in creating a mature, functional human
brain.

MAJOR PROCESSES OF NEURODEVELOPMENT

1. Neurogenesis: The brain develops from cells present in the embryo in the first
weeks following conception. From these few undifferentiated cells, come billions
of nerve cells and trillions of glia. The vast majority of neurogenesis, the “birth”
of neurons, takes place in utero during the second and third trimester. At birth, the
vast majority of neurons used for the remainder of life are present. Few neurons are
born after birth, although researchers have demonstrated recently that neurogenesis
does take place in the mature brain (Gould et al., 1999). Neurogenesis in the mature
brain may be one of the important physiological mechanisms responsible for the
brain’s plasticity (i.e., capacity to restore function) following injury.

Despite being present at birth, most neurons have yet to organize into

completely functional systems. The billions of neurons present at birth need to

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further specialize and connect with other neurons in order to create the functional
neural networks of the mature brain.

2. Migration: As neurons are born and the brain grows, neurons move. Often guided
by glial cells and a variety of chemical markers (e.g., cellular adhesion molecules,
nerve growth factor: NGF), neurons cluster, sort, move and settle into a location
in the brain that will be their final “resting” place. It is the fate of some neurons
to settle in the brainstem, others in the cortex, for example. Cortical cell migration
and fate mapping are some of the most studied processes in developmental neuros-
cience (Rakic, 1981, 1996). It is clear that both genetic and environmental factors
play important roles in determining a neuron’s final location.

Migration takes place primarily during the intrauterine and immediate perinatal

period but continues throughout childhood and, possibly, to some degree into adult
life. A host of intrauterine and perinatal insults – experiences such as infection, lack
of oxygen, exposure to alcohol and various psychotropic drugs can alter migration
of neurons and have profound impact on the expression of genetic potentials for a
host of functions (see Perry, 1988).

3. Differentiation: Neurons specialize during development. Each of the 100 billion
neurons in the brain has the same set of genes, yet each neuron is expressing
a unique combination of those genes to create a unique neurochemistry, neuro-
architecture and functional capability. Some neurons are large, with long axons;
others short. Neurons can mature to use any of a hundred different neurotransmit-
ters such as norepinephrine, dopamine, serotonin, CRF or substance P. Neurons
can have dense dendritic fields receiving input from hundreds of other neurons,
while other neurons can have a single linear input from one other neuron. Each of
these thousands of differentiating “choices” are the product of the pattern, intensity
and timing of various microenvironmental cues, i.e., experience, which tell the
neuron to turn on some genes and turn off others. Each neuron undergoes a series
of “decisions” to determine their final location and specialization. These decisions,
again, are a combination of genetic and microenvironmental cues. Neurons are
specialized to change in response to chemical signals. Therefore, any experience
or event that alters neurochemical or micro-environmental signals during develop-
ment can change the ways in which certain neurons differentiate, thereby altering
the functional capacity of the neural networks in which these neurons reside (e.g.,
Rutledge et al., 1974).

4. Apoptosis: During development, redundant or under-activated neurons die. In
many areas of the brain, there are more neurons born than are required to make
a functional system. Many of these neurons are redundant and when unable to
adequately “connect” into an active neural network will die (Kuan et al., 2000).
Research in this area suggests that these neurons may play a role in the remarkable
flexibility present in the human brain at birth. Depending upon the challenges of the

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environment and the potential needs of the individual, some neurons will survive
while others will not. Again, this process appears to have genetic and environ-
mental determinants. Neurons that make synaptic connections with others and have
an adequate level of activation will survive; neurons with little activity resorb. This
is one example of a general principle of activity-dependence (“use it or lose it”)
that appears to be important in many neural processes related to learning, memory
and development (see below).

5. Arborization: As neurons differentiate, they send out one form of fiber-like
processes called dendrites. Dendrites become the receptive area where other
neurons connect. Dozens to hundreds of other neurons are able to connect to one
neuron via this dendritic tree. The density of these dendritic branches is related
to the frequency and intensity of incoming signals. When there is high activity,
the dendritic network extends. This arborization allows the neuron to receive,
process and integrate complex patterns of input that, in turn, influence its activity
– including the activity and specificity of gene transcription. In turn, the neural
signals coming into any give neuron are often dependent upon the complexity and
activity of the sensory experiences of the animal (Diamond et al., 1966; Greenough
et al., 1973). Dendritic density appears to be one of the most experience-sensitive
physical features of a neuron.

6. Synaptogenesis: The most experience-sensitive feature of a neuron is, however,
the synapse. Developing neurons also send out fiber-like processes which become
axons and synapses. The major mechanism for neuron-to-neuron communication
is ’receptor-mediated’ neurotransmission that takes place at specialized connec-
tions between neurons called synapses. At the synapse, the distance between two
neurons is very short. A chemical (classified as a neurotransmitter, neuromodulator
or neurohormone) is released from the ‘presynaptic’ neuron into the extra-cellular
space (called the synaptic cleft). The neurotransmitter crosses the synaptic cleft
and binds to a specialized receptor protein in the membrane of the ‘postsynaptic’
neuron. By occupying the binding site, the neurotransmitter helps change the shape
of this receptor which results in a cascade of catalyzed chemical reactions mediated
by “second messengers” such as cyclic AMP, inositol phosphate and calcium. In
turn, these chemicals shift the intracellular chemical milieu which will influence
the activity of specific genes. This cascade of intracellular chemical responses
allows communication from one neuron to another.

A continuous dynamic of synaptic neurotransmission regulates the activity and

functional properties of the chains of neurons that allow the brain to do all of its
remarkable activities. These neural connections are not random. They are guided
by important genetic and environmental cues. In order for our brain to function
properly, neurons, during development, need to find and connect with the “right”
neurons. During the differentiation process, neurons send fiber-like projections
(growth cones) out to make physical contact with other neurons. This process

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appears to be regulated and guided by certain growth factors and cellular adhesion
molecules that attract or repel a specific growth cone to appropriate target neurons.
Depending upon a given neuron’s specialization, these growth cones will grow
(becoming axons) and connect to the dendrites of other cells and create a synapse.
During the first eight months of life there is an eight-fold increase in synaptic
density while the developing neurons in the brain are “seeking” their appropriate
connections (Huttenlocher, 1979, 1994). This explosion of synaptogenesis allows
the brain to have the flexibility to organize and function with a wide range of poten-
tial. It is over the next few years, in response to patterned repetitive experiences that
these neural connections will be refined and sculpted.

7. Synaptic sculpting: The synapse is a dynamic structure. With continuous, but
episodic release of neurotransmitter, occupation of receptors, release of growth
factors, shifts of ions in and out of cells, laying down of new microtubules and
other structural molecules, the synapse is continually changing. A key determinant
in this synaptic sculpting process is the level of pre-synaptic activity. When there
is a consistent active process of neurotransmitter release, synaptic connections
will be strengthened with actual physical changes that make the pre- and post-
synaptic neurons grow closer together, making neurotransmission between these
two neurons more efficient.

When there is little activity, the synaptic connection will literally dissolve. The

specific axonal branch to a given neuron will go away. While somewhat simplistic,
it appears that synaptic sculpting is a “use it or lose it” process (see below). This
powerful activity-dependent process appears to be the molecular basis of learning,
memory and, therefore, at the core of neurodevelopment.

8. Myelination: Specialized glial cells wrap around axons and, thereby, create
more efficient electrochemical transduction down the neuron. This allows a neural
network to function more rapidly and efficiently, thereby allowing more complex
functioning (e.g., walking depends upon the myelination of neurons in the spinal
cord for efficient, smooth regulation of neuromotor functioning.) The process
of myelination begins in the first year of life but continues in many key areas
throughout childhood with a final burst of myelination in key cortical areas taking
place in adolescence.

The eight key neurodevelopmental processes described above are dependent

upon the genome and environmentally-determined microenvironmental cues (e.g.,
neurotransmitters, neuromodulators, neurohormones, ions, growth factors, cellular
adhesion molecules and other morphogens). Disruption of the pattern, timing or
intensity of these cues can lead to abnormal neurodevelopment and profound
dysfunction. The specific dysfunction will depend upon the timing of the insult
(e.g., was the insult in utero during the development of the brainstem or at age two
during the active development of the cortex), the nature of the insult (e.g., is there
a lack of sensory stimulation from neglect or an abnormal persisting activation of

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the stress response from trauma?), the pattern of the insult (i.e., is this a discreet
single event, a chronic experience with a chaotic pattern or an episodic event with
a regular pattern?) (see Perry, 2001a).

Several key principles emerge from the research on these neurodevelopmental

processes. These principles, as outlined below, further suggest that while the
structural organization and functional capabilities of the mature brain can change
throughout life, the majority of the key stages of neurodevelopment take place in
childhood.

CORE PRINCIPLES OF NEURODEVELOPMENT

1. Genetic and environmental influences: Genes are designed to work in an
environment. Genes are expressed by microenvironmental cues, which, in turn, are
influenced by the experiences of the individual. How an individual functions within
an environment, then, is dependent upon the expression of a unique combination
of genes available to the human species. We don’t have the genes to make wings.
And what we become depends upon how experiences shape the expression – or
not – of specific genes we do have. For thousands of years, the genetic potential to
use “joysticks” was not expressed – nor that for written language or reading. Yet
when experiences are provided in a structured, patterned and appropriately timed
way, that potential can be expressed and neural systems which mediate all of those
functions will develop.

The influence of gene-driven processes, however, shifts during development.

In the just fertilized ovum, all of the chemical processes that are driving devel-
opment are very dependent upon a genetically-determined sequence of molecular
events. By birth, however, the brain has developed to the point where environmental
cues mediated by the senses play a major role in determining how neurons will
differentiate, sprout dendrites, form and maintain synaptic connections and create
the final neural networks that convey functionality. By adolescence, the majority
of the changes that are taking place in the brain of that child are determined by
experience, not genetics. The languages, beliefs, cultural practices, and complex
cognitive and emotional functioning (e.g., self esteem) by this age are primarily
experience-based.

2. Sequential developmental: The brain develops in a sequential and hierarchical
fashion; organizing itself from least (brainstem) to most complex (limbic, cortical
areas). These different areas develop, organize and become fully functional at
different times during childhood. At birth, for example, the brainstem areas respon-
sible for regulating cardiovascular and respiratory function must be intact for the
infant to survive, and any malfunction is immediately observable. In contrast, the
cortical areas responsible for abstract cognition have years before they will be
‘needed’ or fully functional.

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This means that each brain area will have its own timetable for development.

The neurodevelopmental processes described above will be most active in different
brain areas at different times and will, therefore, either require (critical periods) or
be sensitive to (sensitive periods) organizing experiences (and the neurotrophic
cues related to these experiences). The neurons for the brainstem have to migrate,
differentiate and connect, for example, before the neurons for the cortex.

The implications of this are profound. In the development of socio-emotional

functioning, early life nurturing appears to be critical. If this is absent for the first
three years of life and then a child is adopted and begins to receive attention,
love and nurturing, these positive experiences may not be sufficient to overcome
the malorganization of the neural systems mediating socio-emotional functioning.
Disruptions of experience-dependent neurochemical signals during early life may
lead to major abnormalities or deficits in neurodevelopment. Disruption of critical
neurodevelopmental cues can result from (1) lack of sensory experience during
sensitive periods (e.g., neglect) or (2) atypical or abnormal patterns of necessary
cues due to extremes of experience (e.g., traumatic stress, see Perry, 2001a).

3. Activity-dependent neurodevelopment: The brain organizes in a use-dependent
fashion. As described above, many of the key processes in neurodevelopment
are activity dependent. In the developing brain, undifferentiated neural systems
are critically dependent upon sets of environmental and micro-environmental cues
(e.g., neurotransmitters, cellular adhesion molecules, neurohormones, amino acids,
ions) in order for them to appropriately organize from their undifferentiated,
immature forms (Lauder, 1988; Perry, 1994b; Perry and Pollard, 1998). Lack,
or disruption, of these critical cues can alter the neurodevelopmental processes
of neurogenesis, migration, differentiation, synaptogenesis – all of which can
contribute to malorganization and diminished functional capabilities in the specific
neural system where development has been disrupted. This is the core of a
neuroarcheological perspective on dysfunction related adverse childhood events
(Perry, 2001b). These molecular cues that guide development are dependent upon
the experiences of the developing child. The quantity, pattern of activity and
nature of these neurochemical and neurotrophic factors depends upon the pres-
ence and the nature of the total sensory experience of the child. When the child
has adverse experiences – loss, threat, neglect, and injury – there can be disrup-
tions of neurodevelopment that will result in neural organization that can lead to
compromised functioning throughout life (see below).

4. Windows of opportunity/windows of vulnerability: The sequential development
of the brain and the activity-dependence of many key aspects of neurodevelopment
suggest that there must be times during development when a given developing
neural system is more sensitive to experience than others. In healthy development,
that sensitivity allows the brain to rapidly and efficiently organize in response
to the unique demands of a given environment to express from its broad genetic

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potential those characteristics which best fit that child’s world. If the child speaks
Japanese as opposed to English, for example, or if this child will live in the plains
of Africa or the tundra of the Yukon, different genes can be expressed, different
neural networks can be organized from that child’s potential to best fit that family,
culture and environment. We all are aware of how rapidly young children can learn
language, develop new behaviors and master new tasks. The very same neurodevel-
opmental sensitivity that allows amazing developmental advances in response to
predictable, nurturing, repetitive and enriching experiences make the developing
child vulnerable to adverse experiences.

Sensitive periods are different for each brain area and neural system, and there-

fore, for different functions. The sequential development of the brain and the
sequential unfolding of the genetic map for development mean that the sensitive
periods for neural system (and the functions they mediate) will be when that system
is in the developmental ‘hot zone’ – when that area is most actively organizing. The
brainstem must organize key systems by birth; therefore, the sensitive period for
those brainstem-mediated functions is during the prenatal period. The neocortex,
in contrast, has systems and functions organizing throughout childhood and into
adult life. The sensitive periods for these cortically mediated functions are likely
to be very long.

The simple and unavoidable conclusion of these neurodevelopmental principles

is that the organizing, sensitive brain of an infant or young child is more malleable
to experience than a mature brain. While experience may alter the behavior of
an adult, experience literally provides the organizing framework for an infant and
child. Because the brain is most plastic (receptive to environmental input) in early
childhood, the child is most vulnerable to variance of experience during this time.

Two forms of “neglect” will be considered below: extreme multi-sensory

neglect in childhood and a more subtle, insidious decrease in our opportunities to
elaborate our socio-emotional potential caused by the sociocultural changes in how
we choose to live. The sensory deprivation neglect results in obvious alterations in
neurobiology and function while the second form has an almost invisible toxic
impact on the developing child – and ultimately, society.

The Neurodevelopmental Impact of Neglect in Childhood

Neglect is the absence of critical organizing experiences at key times during
development. Despite its obvious importance in understanding child maltreatment,
neglect has been understudied. Indeed, deprivation of critical experiences during
development may be the most destructive yet the least understood area of child
maltreatment. There are several reasons for this. The most obvious is that neglect
is difficult to “see.” Unlike a broken bone, maldevelopment of neural systems medi-
ating empathy, for example, resulting from emotional neglect during infancy is not
readily observable.

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Another important, yet poorly appreciated, aspect of neglect is the issue of

timing. The needs of the child shift during development; therefore, what may be
neglectful at one age is not at another. The very same experience that is essential
for life at one stage of life may be of little significance or even inappropriate at
another age. We would all question the mother who held, rocked and breastfed her
pubescent child. Touch, for example, is essential during infancy. The untouched
newborn may literally die; in Spitz’ landmark studies, the mortality rates in the
institutionalized infants was near thirty percent (Spitz, 1945, 1946). If one doesn’t
touch an adolescent for weeks, however, no significant adverse effects will result.
Creating standardized protocols, procedures and “measures” of neglect, therefore,
are significantly confounded by the shifting developmental needs and demands of
childhood. Finally, neglect is understudied because it is very difficult to find large
populations of humans where specific and controlled neglectful experiences have
been well documented. In some cases, these cruel experiments of humanity have
provided unique and promising insights (see below). In general, however, there will
never be – and there never should be – the opportunity to study neglect in humans
with the rigor that can be applied in animal models.

With these limitations, however, what we do know about neglect during early

childhood supports a neuroarcheological view of adverse childhood experience.
The earlier and more pervasive the neglect is, the more devastating the develop-
mental problems for the child. Indeed, chaotic, inattentive and ignorant caregiving
can produce pervasive developmental delay (PDD; DSM IV-R) in a young child
(Rutter et al., 1999). Yet the very same inattention for the same duration if the
child is ten will have very different and less severe impact than inattention during
the first years of life.

There are two main sources of insight to childhood neglect. The first is the

indirect but more rigorous animal studies and the second is a growing number of
descriptive reports with severely neglected children.

Environmental Manipulation and Neurodevelopment: Animal Studies

Some of the most important studies in developmental neurosciences in the last
century have been focusing on various aspects of experience and extreme sensory
experience models. Indeed, the Nobel Prize was awarded to Hubel and Wiesel for
their landmark studies on development of the visual system using sensory depriva-
tion techniques (Hubel and Wiesel, 1963). In hundreds of other studies, extremes of
sensory deprivation (Hubel and Wiesel, 1970; Greenough et al., 1973) or sensory
enrichment (Greenough and Volkmar, 1973; Diamond et al., 1964; Diamond et al.,
1966) have been studied. These include disruptions of visual stimuli (Coleman and
Riesen, 1968), environmental enrichment (Altman and Das, 1964; Cummins and
Livesey. 1979), touch (Ebinger, 1974; Rutledge et al., 1974), and other factors that
alter the typical experiences of development (Uno et al., 1989; Plotsky and Meaney,
1993; Meaney et al., 1988). These findings generally demonstrate that the brains of

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animals reared in enriched environments are larger, more complex and functional
more flexible than those raised under deprivation conditions. Diamond’s work, for
example, examining the relationships between experience and brain cytoarchitec-
ture have demonstrated a relationship between density of dendritic branching and
the complexity of an environment (for a good review of this and related data see
(Diamond and Hopson, 1998)). Others have shown that rats raised in environ-
mentally enriched environments have higher density of various neuronal and glial
microstructures, including a 30% higher synaptic density in cortex compared to
rats raised in an environmentally deprived setting (Altman and Das, 1964; Bennett
et al., 1964). Animals raised in the wild have from 15 to 30% larger brain mass
than their offspring who are domestically reared (Darwin, 1868; Rehkamper et al.,
1988; Rohrs, 1955; Rohrs and Ebinger, 1978).

Animal studies suggest that critical periods exist during which specific sensory

experience was required for optimal organization and development of the part of
the brain mediating a specific function (e.g., visual input during the development of
the visual cortex). While these phenomena have been examined in great detail for
the primary sensory modalities in animals, few studies have examined the issues of
critical or sensitive periods in humans. What evidence there is would suggest that
humans tend to have longer periods of sensitivity and that the concept of critical
period may not be useful in humans. It is plausible, however, that abnormal micro-
environmental cues and atypical patterns of neural activity during sensitive periods
in humans could result in malorganization and compromised function in a host of
brain-mediated functions. Indeed, altered emotional, behavioral, cognitive, social
and physical functioning has been demonstrated in humans following specific types
of neglect. The majority of this information comes from the clinical rather than the
experimental disciplines.

THE IMPACT OF NEGLECT IN EARLY CHILDHOOD

:

CLINICAL FINDINGS

Over the last sixty years, many case reports, case series and descriptive studies
have been conducted with children neglected in early childhood. The majority
of these studies have focused on institutionalized children. As early as 1833,
with the famous Kaspar Hauser, feral children had been described (Heidenreich,
1834). Hauser was abandoned as a young child and raised from early child-
hood (likely around age two) until seventeen in a dungeon, experiencing relative
sensory, emotional and cognitive neglect. His emotional, behavioral and cognitive
functioning was, as one might expect, very primitive and delayed.

In the early forties, Spitz described the impact of neglectful caregiving on

children in foundling homes (orphanages). Most significant, he was able to demon-
strate that children raised in fostered placements with more attentive and nurturing
caregiving had superior physical, emotional and cognitive outcomes (Spitz, 1945,
1946). Some of the most powerful clinical examples of this phenomenon are related
to profound neglect experiences early in life.

CHILDHOOD EXPERIENCE AND THE EXPRESSION OF GENETIC POTENTIAL

91

In a landmark report of children raised in a Lebanese orphanage, the Creche,

Dennis (1973) described a series of findings supporting a neuroarcheological
model of maltreatment. These children were raised in an institutional environment
devoid of individual attention, cognitive stimulation, emotional affection or other
enrichment. Prior to 1956 all of these children remained at the orphanage until age
six, at which time they were transferred to another institution. Evaluation of these
children at age 16 demonstrated a mean IQ of approximately 50. When adoption
became common, children adopted prior to age 2 had a mean IQ of 100 by adoles-
cence while children adopted between ages 2 and 6 had IQ values of approximately
80 (Dennis, 1973). This graded recovery reflected the neuroarcheological impact
of neglect. A number of similar studies of children adopted from neglectful settings
demonstrate this general principle. The older a child was at time of adoption, (i.e.,
the longer the child spent in the neglectful environment) the more pervasive and
resistant to recovery were the deficits.

Money and Annecillo (1976) reported the impact of change in placement on

children with psychosocial dwarfism (failure to thrive). In this preliminary study,
12 of 16 children removed from neglectful homes recorded remarkable increases
in IQ and other aspects of emotional and behavioral functioning. Furthermore,
they reported that the longer the child was out of the abusive home the higher
the increase in IQ. In some cases IQ increased by 55 points (Money and Annecillo,
1976).

A more recent report on a group of 111 Romanian orphans (Rutter et al., 1998;

Rutter et al., 1999) adopted prior to age two from very emotionally and physically
depriving institutional settings demonstrate similar findings. Approximately one
half of the children were adopted prior to age six months and the other half between
six months and 2 years old. At the time of adoption, these children had significant
delays. Four years after being placed in stable and enriching environments, these
children were re-evaluated. While both groups improved, the group adopted at a
younger age had a significantly greater improvement in all domains. As a group,
these children were at much greater risk for meeting diagnostic criterion for autism-
spectrum disorder, a finding that sheds light on the evolving relationships between
early life trauma, neglect and subsequent development of severe neuropsychiatric
problems including psychotic disorders and schizophrenia (Read et al., 2001).

These observations are consistent with the clinical experiences of the

ChildTrauma Academy working with maltreated children for the last fifteen years.
During this time we have worked with more than 1000 children neglected in some
fashion. We have recorded increases in IQ of over 40 points in more than 60
children following removal from neglectful environments and placed in consistent,
predictable, nurturing, safe and enriching placements (Perry et al., in prepar-
ation). In addition, in a study of more than 200 children under the age of 6
removed from parental care following abuse and neglect we demonstrated signifi-
cant developmental delays in more than 85% of the children. The severity of these
developmental problems increased with age, suggesting, again, that the longer the

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BRUCE D. PERRY

child was in the adverse environment – the earlier and more pervasive the neglect
– the more indelible and pervasive the deficits.

NEGLECT IN EARLY CHILDHOOD

:

NEUROBIOLOGICAL FINDINGS

All of these reported developmental problems – language, fine and large motor
delays, impulsivity, disorganized attachment, dysphoria, attention and hyper-
activity, and a host of others described in these neglected children – are caused by
abnormalities in the brain. Despite this obvious statement, very few studies have
examined directly any aspect of neurobiology in neglected children. Yet clues exist.
On autopsy, the brain of Kasper Hauser was notable for small cortical size and few,
non-distinct cortical gyri – all consistent with cortical atrophy (Simon, 1978).

Our group has examined various aspects of neurodevelopment in neglected

children (Perry and Pollard, 1997). Neglect was considered global neglect when
a history of relative sensory deprivation in more than one domain was obtained
(e.g., minimal exposure to language, touch and social interactions). Chaotic neglect
is far more common and was considered present if history was obtained that
was consistent with physical, emotional, social or cognitive neglect. History was
obtained from multiple sources (e.g., investigating CPS workers, family, and
police). The neglected children (n = 122) were divided into four groups: Global
Neglect (GN; n = 40); Global Neglect with Prenatal Drug Exposure (GN+PND;
n = 18); Chaotic Neglect (CN; n = 36); Chaotic Neglect with Prenatal Drug
Exposure (CN+PND; n = 28). Measures of growth were compared across group
and compared to standard norms developed and used in all major pediatric settings.

Dramatic differences from the norm were observed in FOC (the frontal-occipital

circumference, a measure of head size and in young children a reasonable measure
of brain size). In the globally neglected children the lower FOC values suggested
abnormal brain growth. For these globally neglected children the group mean was
below the 5th percentile. In contrast, the chaotically neglected children did not
demonstrate this marked group difference in FOC. Furthermore in cases where
MRI or CT scans were available, neuroradiologists interpreted 11 of 17 scans as
abnormal from the children with global neglect (64.7%) and only 3 of 26 scans
abnormal from the children with chaotic neglect (11.5%). The majority of the
readings were “enlarged ventricles” or “cortical atrophy” (see Figure 1).

In following these globally-neglected children over time we observed some

recovery of function and relative brain-size when these children were removed
from the neglectful environment and placed in foster care (see Figure 2). The
degree of recovery over a year period however was inversely proportional to age in
which the child was removed from the neglecting caregivers. The earlier in life and
the less time in the sensory-depriving environment, the more robust the recovery.

These findings strongly suggest that when early life neglect is characterized by

decreased sensory input (e.g., relative poverty of words, touch and social interac-
tions) there will be a similar effect on human brain growth as in other mammalian

CHILDHOOD EXPERIENCE AND THE EXPRESSION OF GENETIC POTENTIAL

93

Figure 1. Abnormal brain development following sensory neglect in early childhood. These
images illustrate the negative impact of neglect on the developing brain. In the CT scan on the
left is an image from a healthy three year old with an average head size (50th percentile). The
image on the right is from a three year old child suffering from severe sensory-deprivation
neglect. This child’s brain is significantly smaller than average (3rd percentile) and has
enlarged ventricles and cortical atrophy.

species. The human cortex grows in size, develops complexity, makes synaptic
connections and modifies as a function of the quality and quantity of sensory
experience. Sensory-motor and cognitive deprivation leads to underdevelopment
of the cortex in rats, non-human primates and humans.

Studies from other groups are beginning to report similar altered neurodevel-

opment in neglected children. In the study of Romanian orphans described above,
the 38% had FOC values below the third percentile (greater than 2 SD from the
norm) at the time of adoption. In the group adopted after six months, fewer than
3% and the group adopted after six months 13% had persistently low FOCs four
years later (Rutter et al., 1998; O’Connor et al., 2000). Strathearn (submitted) has
followed extremely low birth weight infants and shown that when these infants end
up in neglectful homes they have a significantly smaller head circumference at 2
and 4 years, but not at birth. This is despite having no significant difference in other
growth parameters.

More recently advanced neuroimaging techniques have demonstrated altered

brain development in neglected children. Chugani and colleagues have been pion-
eers in neuroimaging studies in maltreated children. Their most recent study
using functional MRI in Romanian orphans has demonstrated decreased metabolic
activity in the orbital frontal gyrus, the infralimbic prefrontal cortex, the amygdala

94

BRUCE D. PERRY

Figure 2. Sensory deprivation neglect: effects of early removal on recovery. Children were
removed from neglectful environments at different ages (ages 8 months to 5.7 years). Their
frontal-occipital circumference was measured and compared to same-aged norms (blue bars).
Children were placed in foster care and one year later re-evaluated. FOC was measured
(maroon bars) and in each group increased although with increasing age, the improvement
after a year of foster placement started to decrease such that children removed after four years
in the neglectful setting had no statistically-significant improvement one year later. Data are
from 112 children with some form of severe neglect in the first five years of life (modified
from Perry and Pollard, 1997).

and head of the hippocampus, the lateral temporal cortex and in the brainstem
(Chugani et al., 2001). Together these findings suggest a global set of abnormalities
matched by the functional abnormalities in cognitive, emotional, behavioral and
social functioning.

EMOTIONAL NEGLECT IN EARLY CHILDHOOD

:

THE UNDER

-

EXPRESSION OF

SOCIO

-

EMOTIONAL POTENTIAL

Clinical attention has been focused on extremes of neglect. The obvious clinical
syndromes which result from pervasive neglect have facilitated research in this
area. More recently, however, many researchers have observed and studied abnor-
malities in the capacity of children – and adults – to form healthy relationships. An
emerging area of study is focusing on “attachment” – a special form of emotional
bond. While usually not framed in context of developmental neglect, attachment
problems in children often are the result of mistimed, abnormal or absent care-
giving interactions and, therefore, may represent a special case of neglect. As with
other brain-mediated capabilities, the capacity to form relationships results from

CHILDHOOD EXPERIENCE AND THE EXPRESSION OF GENETIC POTENTIAL

95

the experience-based expression of an underlying genetic potential to create the
neural systems mediating socio-emotional behaviors.

At birth an infant has yet to form a true relational bond with another person.

In most instances, the infant will be cared for by an attentive, attuned and loving
caregiver. When this happens, a caregiver will, again and again, come to the hungry
or cold or scared infant. Warming, soothing, feeding, cleaning and calming the
infant, the caregiver creates a set of specific sensory stimuli which are translated
into specific neural activations in areas of the developing brain destined to become
responsible for socio-emotional communication and bonding. The somatosensory
bath – the smells, sights, sounds, tastes and touch – of the loving caregiver provides
the repetitive sensory cues necessary to express the genetic potential in this infant
to form and maintain healthy relationships. This first and most primary of all
relationships is this attachment bond.

The attachment bond has several key elements: (1) an attachment bond is an

enduring emotional relationship with a specific person; (2) the relationship brings
safety, comfort, soothing and pleasure; (3) loss or threat of loss of the person
evokes intense distress. This special form of relationship is best characterized
by the maternal-child relationship. The maternal-child attachment provides the
working framework for all subsequent relationships that the child will develop.
A solid and healthy attachment with a primary caregiver appears to be associated
with a high probability of healthy relationships with others while poor attach-
ment with the mother or primary caregiver appears to be associated with a host
of emotional and behavioral problems later in life. More than 85% of children
removed from their parents for abuse or neglect have disturbed attachment capacity,
for example (Carlson et al., 1989). The relationships between disordered attach-
ment and increased risk for violent and aggressive behaviors are well documented
(see Perry, 2001a).

THE MODERN WORLD AND NEGLECT OF SOCIO

-

EMOTIONAL GROWTH

Healthy attachment capacity is not enough to create healthy socio-emotional func-
tioning. Attachment is only one form of the many kinds of relationships we
form to create a healthy productive life. Certainly a securely attached child will
have an easier time forming friendships, relationships with teachers, coaches,
siblings and, over time, in the work place and larger community. As the brain
organizes and develops in response to patterned, repetitive experience, the nature,
timing, intensity and quality of an array of other relationships in the developing
child’s life will make a difference in the development of complex socio-emotional
development. Yet without the opportunities to have friends, teachers, coaches,
grandparents, neighbors, team mates and the many other kinds of relationships
of childhood, these capabilities remain unexpressed. And if a child starts with
attachment problems and has few opportunities to develop other relationships, they
will have very poor or even pathological socio-emotional functioning.

96

BRUCE D. PERRY

Figure 3. Decrease of number of persons living in a “household” in Western societies: From
hunter-gatherer to the modern era. For more than 90 percent of human history we have lived
in bands, clans or extended families of roughly 40 persons. In the West, by 1500 the average
household had decreased to 20 persons; by 1850 to ten; in the United States to less than three
persons in the average American household by 2000.

Our brain evolved over hundreds of thousands of generations in hominid and

pre-hominid social groups. In these small hunter-gatherer bands a complex inter-
active dynamic socio-emotional environment provided the experiences for the
developing child. At equilibrium in a group of fifty, there were three or more adult
caregiving adults for every dependent child under age six. And there was little
privacy. A dependent child grew up in the presence of the elderly, siblings, adults
– related and not. There was a more continuous exposure and wider variety of
socio-emotional interactions. The child in this situation had many opportunities
to form relationships and, in a use-dependent way, develop the capacity to have
a rich array of relationships. The genetic potential for healthy socio-emotional
functioning – to be empathic, to share, to invest in the welfare of the community –
is better expressed in children living in hunter-gatherer bands or extended families
or close-knit communities in comparison with our compartmentalized modern
world.

In this modern era, we separate from each other in many ways. The number

of people we live with has shrunk (Figure 3); fewer than three people live in the
average American household. And in our own homes, we have our own rooms. We
rarely eat family meals. We spend thirty percent of our available time watching tele-
vision – certainly not allowing for any use-dependent expression of an underlying
genetic capacity for socio-emotional functioning. Our children are segregated with
same age children for hours a day. In healthy homes the time a parent spends with
older children is counted in minutes. We think a healthy ratio of adult caregiver to
dependent child in our child care settings is one adult for five children – 1/16th the

CHILDHOOD EXPERIENCE AND THE EXPRESSION OF GENETIC POTENTIAL

97

ratio in a hunter-gatherer clan. We have over-scheduled our children and they have
little time for spontaneous social play with peers.

The inadvertent effect of our modern advancements in lifestyle, communica-

tions, technology and economies is that we are now raising children in environ-
ments that are very different from the rich social context for which our brains are
most suited. The effects of television and other electronic activities have signifi-
cantly exacerbated this. Taking huge portions of the available day away from
socio-emotional or other “human” activities, television ensures that new – and
non-social – neural systems are being activated in comparison with humans raised
one hundred years ago. The implications of this have yet to be fully understood
although some indications suggest that we are losing “social capital.” One indicator
of this is the percentage of individuals who volunteer and vote. From 1972 to 2000,
the percentage of young adults (age 18–24) voting in the Presidential election fell
from 47% in 1972 to 27% in 1996 to 23% in 2000!

Summary and Future Directions

The many functions of the human brain result from a complex interplay between
genetic potential and appropriately timed experiences. The neural systems respon-
sible for mediating our cognitive, emotional, social and physiological functioning
develop in childhood and, therefore, childhood experiences play a major role in
shaping the functional capacity of these systems. When the necessary experiences
are not provided at the optimal times, these neural systems do not develop in
optimal ways.

Healthy development of the neural systems which allow optimal social and

emotional functioning depends upon attentive, nurturing caregiving in infancy
and opportunities to form and maintain a diversity of relationships with other
children and adults throughout childhood. In our modern world, we are more
mobile, compartmentalized and socially-disconnected. The true costs of our life-
style choices may be difficult to see; yet an understanding of neurodevelopment
suggests that the modern world’s socio-emotional milieu is not sufficient for
most children to express their true potential for forming and maintaining healthy
relationships.

As a society, we value cognitive development and, therefore, provide consistent,

repetitive and enriching cognitive experiences in the home and through our educa-
tional systems. In an age where more people must share increasingly limited
resources, however, it is imperative that our children develop the capacity to
share, be empathic and understanding of others. We must provide an investment
in socio-emotional development comparable to our investment in cognitive devel-
opment. The world, natural and manmade, now more than ever, needs the best of
humankind.

98

BRUCE D. PERRY

Acknowledgements

This work has been supported in part by grants from the Brown Family Found-
ation, the Hogg Foundation for Mental Health, the Children’s Justice Act, the
Court Improvement Act, Texas Department of Protective and Regulatory Services,
Maconda Brown O’Connor and the Pritzker Cousins Foundation. Portions of this
article were first presented at the Society for Neuroscience Meetings in 1997
in New Orleans. Elements of this article were adapted from Perry, B.D., 2001:
The euroarcheology of childhood maltreatment: the neurodevelopmental costs of
adverse childhood events. In K. Franey, R. Geffner, and R. Falconer (eds), The Cost
of Maltreatment: Who Pays? We All Do. San Diego: Family Violence and Sexual
Assault Institute, pp. 15–37.

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